December 11, 2012
PPD/TMS Peer Network  December Newsletter
mustache man and doctor
Dear Friends and Colleagues,

As we come to the last month of 2012, I am reminded about how much progress both the PTPN and the PPD movement as a whole have made over the past year. The PPDA conference in October was very successful at educating practitioners about PPD. Likewise, the PTPN has grown substantially over the past year and is now a 501(c)(3) organization. All of you have played a role in the success of these two organizations and in raising awareness for PPD. I am very excited about what 2013 has in store for us!


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In This Edition
  1. Peer Supervision Teleconference with Alan Gordon
  2. Special Webinar with David Schechter and Arnold Bloch
  3. Recording of the 2012 PPDA Conference: When Stress Causes Pain
  4. The Bio-Technological Approach to Back Pain: Dangerous Road Ahead, by Howard Schubiner, MD
  5. Interview with the Rocky Mountain Stress Check-Up Network

Peer Supervision Teleconference with Guest Alan Gordon, LCSW

The next P AlanGordon eer Supervision Teleconference will be on Saturday, January 12th from 1:00 to 2:30 PM EST. The guest speaker will be PPD Therapist and PPDA board member Alan Gordon, LCSW.

Alan's presentation will focus on increasing clients' ability to accept the PPD diagnosis, and how to help clients reduce their fear of the symptoms.

Webinar with David Schechter, MD and Arnold Bloch, LCSW

On November 14th, the PTPN hosted a special webinar event with David Schechter, MD and Arnold Bloch, LCSW. This event covered a variety of PPD-related issues from the perspective of both a physician and a therapist. It was very enlightening to learn about PPD from these two different perspectives.

The audio of this event has been posted on our forum where it can be listened to and downloaded. To hear this wonderful event please visit Special Webinar with Dr. David Schechter and Arnold Bloch, LCSW.

When Stress Causes Pain Conference

The PPDA has posted several recordings of the 2012 NYC conference on YouTube.
Because the YouTube videos do not include the slides, I made a companion video that includes the slides for the first three presentations. Because the first three presentations rely on the slides, viewing the slides and speaker simultaneously offers, I think, the best experience.

The Bio-Technological Approach to Back Pain: Dangerous Road Ahead, by Howard Schubiner, MD

In October, health officials reported a Meningitis outbreak stemming from contaminated steroid shots exposing over 14,000 people. As of late November over 19 states have reported cases with the death toll reaching 36 people. Dr. Howard Schubiner addressed this issue in a recent blog post that has been reposted here with his permission.


Schubiner VPThe scandal of cortisone injection material tainted with fungi has created a large burden of illness and death among a small proportion of individuals who received epidural injections for back pain. Calls for better regulation and oversight of compounding pharmacies are being made of the FDA and other governmental agencies. However, another story that may ultimately be more important needs to be highlighted. How many of these injections were indicated and how many were likely to be helpful to those receiving them? Unfortunately, studies demonstrate that the majority of these injections are not indicated and not effective.

In all medical decisions, it is incumbent upon the physician to calculate an analysis of the likely benefit of a given treatment versus the potential risk. This calculation is at the heart of all good medical practice.  When a treatment is effective, doctors and patients are often willing to choose treatments that have a significant risk, such as is common in people with cancer. Another reason to tolerate treatment with significant risk is for conditions that are severely disabling, again as with cancer.

Medical decision-making for people with back pain has been very similar to that of cancer.  Back pain is viewed by both doctors and patients as a severely disabling process that is likely to be chronic and unresponsive to simple interventions.  Therefore, invasive treatments such as epidural and other injections, back surgery, and the use of opioid narcotic medications are commonly prescribed.  The potential risk of these treatments is great as demonstrated by the fungal meningitis outbreak.  In addition to this potential complication, the risks of surgery are well known, such as paralysis, infection, increased pain, and the need for re-operation.  Opioids have been shown to have tremendous risk, having the potential for addiction, overdose and death, and the development of hyperalgesia, i.e., sensitizing the brain to actually experience more rather than less pain.  Of course, the costs for back pain treatment are astounding, amounting to at least $100 billion per year in the U.S.

Speaking of the costs of treating back pain, the number of MRIs, injections, opiate prescriptions, and back surgeries has risen by 200-300% in the last decade or so, yet the rates of those with disabling back pain has also risen (by about 25%).  What we are doing is clearly not working.
From my point if view, the problem is this: We are using the wrong approach for the majority of people with back pain.  Only a small proportion of back pain is caused by a clear pathological entity, such as a tumor, fracture, infection or obvious nerve root damage. These causes are estimated to comprise about 10-15% of those with back pain.  The rest are likely caused by psycho-physiologic processes.  This concept is so foreign to most people (and to most doctors) that it likely to be rejected out of hand.  Yet, it is true.  Minor "abnormalities" on MRIs are typically presumed to cause pain when there is no evidence that is the case.  Abnormal MRIs occur in the majority of adults who have no back pain.  Cutting edge neuroscience demonstrates that pain can be caused by the brain and that emotions lower the pain threshold.  It is well known that the brain can create symptoms as severe as paralysis; this is called a conversion disorder. It seems clear that the brain is also capable of creating pain and many other symptoms.
What is not appreciated is that stress is the most common cause for chronic back pain (and other conditions such as chronic headaches, irritable bowel syndrome, and fibromyalgia).  All pain is real -- very real!  Pain not caused by structural problems (e.g., fractures, tumors, infections) is caused by neural pathways that have been "learned" by the brain and create real physical pain.  Careful histories of people with severe chronic pain uniformly uncover the underlying causes of the pain.  Briefly, the situations that cause psycho-physiologic pain are those where an individual has been sensitized by stressful life events earlier in life (e.g., a controlling or abusive relative) and later a triggering event occurs such as a physical or emotional trauma that creates fear, anger, or guilt along with a sense of being trapped or feeling helpless.  Severe pain develops as a reaction to these scenarios.  The reason doctors never notice these connections is that they never take the time to look for them.
There is now an emerging body of literature showing that treatment of chronic back pain is effective when one uses a psycho-physiologic approach.  We are in the process of publishing data showing that the majority of patients with severe chronic back pain can recover.  This treatment approach is very cost-effective.  In fact, it often only requires a change in how one views the cause of the pain and simple behavioral steps to change the nerve pathways causing pain.  Dr. John Sarno has sold approximately a million books describing this model.  From anecdotal reports, about 10% of those who have read one of these books have had rapid recoveries from chronic back pain.  Can we learn something from 100,000 people?  Most back pain (and other chronic painful conditions) can be cured.  The current bio-technological approach of opiates, injections, and surgery is making us worse, rather than better.  Millions of back pain sufferers need help and this help is closer than we think.
To your health,

Howard Schubiner, MD

Interview with the Rocky Mountain Stress Check-Up Network
A group of therapists based in the Denver, Colorado area have recently formed a professional network called the Rocky Mountain Stress Check-Up Network.  The goal of this group is to forge relationships with physicians and provide their patients with a Stress Check-Up and treatment for PPD. The group consists of Catherine Tilford, Jennifer DeVault, Aimee Aron, Nancy Turley, and Sarah White. They have been trained and mentored by PPD physician and PPDA board member David Clarke, MD. The PTPN recently interviewed the members of this group about the mission of the organization and what they hope to accomplish.

PPD/TMS Peer Network (PTPN): How long have you been in practice?

Catherine Tilford (CT):  I have been in private practice for a year and a half.

Jennifer DeVault (JD): I opened my private practice in October 2011.  Prior to venturing out on my own, I was an intern at a community center and at a private practice in Colorado.  
Aimee Aron (AA):  I have had my own practice for a year and a half, and been seeing clients for about three years now.

Nancy Turley (NT): Two years.

PTPN: What is your area of focus?

CT:  I have a few different areas of focus in my private practice.  They include: eating disorders and body image issues; depression and anxiety; self-harm; personal growth; and stress.  

JD: I work with individual adults and couples.  I approach therapy from a cultural perspective and assist individuals in identifying the life that they want to live.  I have worked with individuals struggling with depression, anxiety, bi-polar, and issues of gender and sexual orientation.  My integrative approach includes CBT, EFT, attachment theory, existential theory, and feminist theory.   

AA:  I work with individual adults who are struggling with anxiety, depression, self-esteem and identity challenges, as well as grief and loss.  I’ve found that many people experience feelings of depression or anxiety and are uncertain as to why they are suffering with these feelings.  Via psychotherapeutic work we work to develop an understanding of the root of these feelings, which often times have roots in those subjects of self-esteem and identity and grief or loss.  I work to help people understand what their individual experience is and means to them, and to develop a sense of agency in how they want to address and work through those challenging feelings and experiences. I then support them in doing so. I work to help people to trust in themselves and their resilient nature.

I also provide culturally respectful counseling to members of Indigenous populations, specifically individuals of American Indian, Alaska Native and First Nations descent. This is a population I respect very much, have developed, and continue to develop educational and personal understanding of and experience within.

NT: I am still getting established but I work with individuals and couples with depression, anxiety and relationship issues. I also work with substance abuse and addictions.

PTPN: Of those years how long have you treated PPD patients?

CT:  I officially began treating PPD patients after receiving training from Dr. David Clarke in November of 2011.  Previously, I worked in college mental health centers and the medical setting and after receiving Dr. Clarke’s training; I realized I had worked with people in those settings who were experiencing PPD although I didn’t know that name for it at the time.

JD: I began working with the PPD population when I began my practice.

AA: I incorporated a focus of PPD into my practice in January of 2012 after being trained by Dr. Clarke.  However, I believe that a lot of folks experience physical symptoms of their emotional distresses, so I’ve seen many clients in my career thus far who suffer from some degree of symptoms related to stress or PPD.

NT: For about the last year I have been trying to get referrals.

PTPN: How did you learn about PPD?

CT:  I am part of a professional group of therapists that meets monthly for peer consultation.  One of the members of the group, Nancy Turley, MA, NCC, met Dr. David Clarke at a professional conference and shared information about PPD with our group when she returned.  She asked us if we would be interested in being trained by Dr. Clarke on PPD and I immediately knew it was something that I was interested in.  As Nancy was talking about Dr. Clarke’s work, I was thinking of current and past clients who had suffered from physical symptoms caused by stress and spent years going to doctors and undergoing tests only to find out that there was no medical explanation for their symptoms.  I also have personally experienced the toll stress can take on one’s physical health and after prioritizing my own self-care have experienced increased health and vitality.  Therefore, I was very interested in receiving training from Dr. Clarke and filling this need in the Denver area.    

JD: My colleague and office mate, Nancy Turley, connected our group with Dr. Clarke.

AA: Nancy Turley, one of the other co-founding members of the Rocky Mountain Stress Check-Up Network introduced me to the concept about a year ago.  She had met with Dr. Clarke and was very interested in his work.  She shared his book with me, and I felt that his findings were so intriguing and valid that I had to learn more.  I felt and continue to feel that PPD is a topic that deserves much more attention and validation, and I wanted to be a part of helping a greater amount of people understand how stress may be affecting them, someone they love, or someone they see as a client or patient.

NT: Through Dr. David Clarke who spoke to a friend’s book club about his book.

PTPN: Who all is involved with the Rocky Mountain Stress Check-Up Network?

CT: The Rocky Mountain Stress Check-Up Network was co-founded by Nancy Turley, MA, NCC; Jennifer DeVault, MA, NCC; Aimee Aron, MA, NCC; and myself.  After forming the network in the fall of 2010, Sarah White, Psy.D., joined our group and was trained by Dr. Clarke.

PTPN: What does this group hope to accomplish? What are its aims and mission?

CT: Our aim when forming the Rocky Mountain Stress Check-Up Network was to establish a group of mental health professionals trained by Dr. Clarke who could serve as a referral network to patients suffering from PPD and the doctors who treat them.  Within the medical community, it is best practice to refer patients to specialists when needed (i.e. Orthopedists, Gastroenterologists, etc.) and by forming our group; we hope to provide the medical community with a group of specialists whom they can refer their patients to who are suffering from stress-related illnesses.  Our mission is to bridge the gap between medical and mental health care for people who are experiencing physical symptoms and frustration and hopelessness because they cannot find a medical cause or relief from their symptoms.  The Rocky Mountain Stress Check-Up Network is a group of mental health specialists who can help the patient evaluate whether his or her symptoms are the result of stress through the stress check-up and provide treatment in the form of talk therapy.

NT: We are trying to get out the awareness of the connection between physical symptoms and stress and trauma and offer solutions to the many people out there who are suffering and can’t find relief through medical channels.

PTPN: What were your motives behind starting the organization? What do you hope to accomplish with the group?

AA: The four original members, Nancy, Jennifer, CT: and myself have been peers for several years.  We felt that joining forces and developing this organization gave us a unified platform and message to reach members of the medical and mental health communities, and provided a number of referral resources for those folks who may want to explore how PPD is a part of their experience, via therapy.

Our hopes for the Rocky Mountain Stress Check Up Network are multi-faceted. We hope to reach the medical and mental health communities to provide information and a greater understanding of PPD and what it can look like.  We do this by visiting and talking to doctor’s offices, clinics and hospitals, distributing our information and being available to speak with members of these professions about PPD, and how we may be a resource for them and their patients. We also hope to reach individuals who may be experiencing symptoms of PPD themselves. Each of us are trained therapists who offer a space to safely explore possible indicators of stress in an individual’s daily experience. We strive to provide assessment of, insight into, support, and healing from a person’s identified stressors.

NT: Offering a service to people who are under served at this time. I was also hoping to create a new referral source through the connection with medical offices.

PTPN: Your organization was trained by Dave Clarke. What did this training entail and what role does Dr. Clarke play in the organization?

AA: Our training began when Dr. Clarke invited us to attend a presentation of his findings. He shared how his experience over the last several decades and working with over 7,000 people helped him to understand how stress and/or trauma from various aspects of a person’s life can contribute to physical symptoms.  Dr. Clarke explained how he has been able to identify symptoms of PPD in patients who may visit doctor after doctor without any kind of diagnosis or answer to why they may be suffering. His experiences demonstrated to him that there is a gap in interpretation of how our emotional well being may be affecting our physical health, and that there is an opportunity to bridge that gap by bringing understanding of this phenomenon and how to pinpoint it to medical and mental health professionals.  From here the term “Stress Check-Up” came into play, as it provides medical professionals with a way to introduce the concept of stress and how it may be affecting their patient physically. The training provided insight into how mental health professionals such as ourselves can be the next phase to provide help to these patients and clients by providing the Stress Check-Up service.  Dr. Clarke’s training provided guidance as to asking questions that could help determine when indicators of Stress Illness may have begun, and the client or patient’s current experience of these symptoms.

Dr. Clarke is the mentor and guide to our organization. He speaks about his findings with local hospitals and medical organizations, and we are there to support him with information about Stress Illness and the Rocky Mountain Stress Check-Up Network.  He has made himself available to each of us to answer any questions we may have about how to assess and conceptualize the experience of a client that is coming to see us for stress-related symptoms. He is also a fantastic resource for us on how to help continue to bridge the gap between the medical and mental health fields, to work to speak one another’s languages, and in doing so, to be able to help more clients and patients suffering from Stress Illness.

NT: We met with Dr. Clarke for an afternoon training session where he talked and went through a slide presentation. I have several meetings with him over coffee and we have attended his lectures in Denver hospitals.

PTPN: Many of the people who will be reading this are therapists across the globe, who, at some point, may be interested in developing a regional network in their city. How did you reach out to physicians? What specialties did you focus on (i.e. primary care physicians, emergency room doctors)?

JD:  I started by reaching out to my own physicians.  I believe having a personal relationship with the physician is essential to building referrals.  I have focused on primary care physicians and OB/GYNs.  Dr. Clarke also presented at some of our area hospitals during grand rounds.  I have successfully built a referral from one of his presentations.

NT: We came up with a brochure and cover letter for physicians. I sent it out to about 12 medical offices and followed up with a phone call. I focused on internists, a dermatologist and gastroenterologists. I heard back from the dermatologist and did a presentation to the staff there on what we can offer. They were very responsive and glad to
have referrals to give but to date no one has scheduled an appointment.

PTPN: Physicians want to find a way to help these patients with medically unexplained symptoms. From your experience, what is the best way to explain PPD to these physicians, and how you can help their patients?

CT: The best way to explain PPD to physicians is by using their language which Dr. Clarke has helped us with through training and support as we network with physicians.  It is important that we describe exactly what the stress check-up entails and the service we provide to their patients.  I also think that sharing case examples both from Dr. Clarke’s work and our own work is important to demonstrate positive outcomes and illustrate how we can help their patients.    

JD: As a group, we have attempted to take away the stigma of mental health care by framing our services as “referring to another specialist.”  Our literature is tailor to both the medical community and their patients.  I offer an assessment that is tailored to individuals experiencing stress illness.

AA: We recognize that many healthcare professionals in today’s world are so busy, they need a streamlined way to understand symptoms of PPD, and what can be done to help.  Our network has developed some simple and easy to understand literature for the physician, as well as for the patient. Through our efforts as an organization, when we reach out to doctor’s offices we ask to speak to the staff during a lunch meeting, or other time when we can reach the most staff with a consistent message. We discuss what a patient who may be suffering from PPD may look like; including common symptoms they may be experiencing, frequency of visits to their office, etc. We explain that the common feeling among these patients is frustration as they search for answers to questions such as “What is wrong?” and “Why do I feel this way?” The physician can help that patient by validating their experience and letting them know that another option to explore is to have a Stress Check Up, as medical tests may not always be able to reveal causes of the physical symptoms they are having.  By meeting with staff we have an opportunity to speak face to face with them, and for them to meet us – so they know who they may be referring a patient to for a Stress Check-Up. They have an opportunity to ask us any questions about ourselves, our practices or our methods. This provides information into how we can help, what we have learned from our experiences, training and ongoing relationship with Dr. Clarke, how we assess what kind of stress a person may have been or is currently going through, and how this manifests for that individual. Dr. Clarke put it best when he said there are two main concepts we want people to understand, “Stress causes real symptoms, and effective treatment is available.”  We strive to provide easy to understand information and approachable options for assisting the patients that medical providers may feel unsure of how to help further.

NT: I offered a free stress check up. I am finding there is a gap between the patient hearing about a stress check up as an option and making the call for an appointment.

PTPN: What are the benefits of using the term “Stress Check-Up” instead of psychological evaluation?

AA: Unfortunately in our society, there is a lot of stigma surrounding mental health.  Due to this current culture, using the term psychological evaluation may cause a person to unnecessarily feel labeled and misunderstood as having a condition for which they feel shame.  Sometimes this shame prevents a person from seeking further help, which means continued suffering. We believe use of the term “Stress Check-Up” is an accurate depiction of what a person will experience in coming to talk with any of us within the Rocky Mountain Stress Check-Up Network. We are trained to ask important questions about current or previous stresses in a person’s life to help determine the root cause of undiagnosed physical symptoms. This process of evaluating stress in a person’s life can help them to find relief from their symptoms, determine ways to manage stress, and to find ways to get more enjoyment out of their life.  Stress is ubiquitous, and a shared element of the human experience.  If we can help people identify and talk about how stress affects them, we can bring about greater understanding and an opportunity to open up discussion of the subject of stress and PPD with others.

NT: We thought it would be closer to layman’s terms and connect with the potential client making them feel less of a stigma, not having to relate to a mental “condition.” So far, it is still difficult to get people to see the benefit in talking or being listened to rather than to get a “pill.”

PTPN: Most individuals with PPD are misdiagnosed by physicians.  What role do you hope to play in working with physicians to treat clients with PPD? How many referrals has your group received from the physicians you reach out to?

JD:  I view my role in working with physicians as one of relationship building, increasing awareness of stress illness, and offering a viable treatment for stress illness.  I am unsure of the total number of referrals for the group.  I have received one referral thus far.  I believe there is an overall curiosity regarding stress illness.  Generally, I have found individuals to be receptive to the information.

NT: I have had 2 potential referrals that I know of but in both instances, the patient has not called for the free consultation or stress check up.

PTPN: When, or if, a physician refers a patient to see you or another member of the organization, what processes do you have in place to see the patient? Does the physician refer the patient to the group or to a specific member of the group? Approximately how long will it usually take for the referred patient to see one of you? What follow up is there both in terms of return visits from the client and from the physician?

JD: We all own and operate our practices separately.  The physician would refer the patient directly to a member of the group.  Generally, the patient would be able to see one of us within a week of referral depending on their availability and our case loads.  If one of us was unavailable, we would provide a referral to another individual in our group.

I offer a free 30 minute consultation for individuals to meet me and ask questions regarding my services. If the patient felt comfortable with me, I would schedule a stress illness assessment for the next session.  I would then work with the client to schedule sessions based on their needs.  As a standard of my practice, I would request that the client sign a release of information for me to work directly with the referring physician.

PTPN: What challenges are there in starting something up like this?

CT: One of the biggest challenges we face is de-stigmatizing therapy and referral to a mental health professional.  I have worked with clients who experienced unexplained physical symptoms and after a few years of working with doctors, they contacted me for counseling.  For them, it was the next logical step since medical treatments weren’t helping and there was no explanation for their symptoms except for stress.  Unfortunately, there are many people who experience unexplained physical symptoms and continue to see doctor after doctor and undergo test after test because they do not believe their symptoms could be related to stress or have a stigmatized view of therapy.  The challenge becomes reaching those people who have never considered or been open to therapy and helping them understand that mental health professionals are another type of specialist within the healthcare community and are trained to help people suffering from stress-related illnesses.    

Other challenges have included deciding how our network was going to function and whether we were open to allowing other mental health professionals to join the network.  There were many questions when we were first forming the network as to how we were going to maintain quality control in regard to services and messaging.  We decided to create all of our marketing materials together so that the message would be consistent across all of our individual practices.  We also decided that if other mental health professionals were interested in joining our group and received training by Dr. Clarke, they were welcome to join our referral network.  Finally, we put a lot of thought into naming our network because we didn’t want it to limit us in terms of location and potential expansion.  Therefore, we decided on the Rocky Mountain Stress Check-up Network so that if some day the network grows beyond the Denver Metro area, the name will still be relevant.

NT: Communication and connections. It takes some investment of time and money to reach out and explain to physicians and their patients.

PTPN: Many people have written about how medicine has a blind spot regarding psychophysiologic disorders. In your opinion, why has this approach not caught on in the medical community, and how can the PPD community work to change that?

NT: Lack of education in the medical diagnostic field when there are so many medical diagnostics to learn. But there is also the mind-set by most people who go to a physician that the physician will “cure” them. They want their problem to be physical and not mental, which carries a stigma and infers they have to look deeper and take responsibility. I think most people don’t want to be that responsible for their health, physical or mental. The standard is a “quick fix” and anything more, requires a change in mind set!

PTPN: How did you become involved with the Rocky Mountain Stress Check-Up Network and what role will you be playing in the group?

Dave Clarke (DC): A recently trained therapist heard about my work and contacted me. I offered to provide a ½ day of training and the therapist brought three of her colleagues to this session. They were excited about the possibilities for helping PPD patients and formed the RMSCN soon thereafter. I provided additional support by mentioning their availability and expertise in lectures at two of Denver’s largest teaching hospitals. I provide ongoing mentoring and advice.

PTPN: What is entailed in a Stress Check-Up and what are the benefits of this term?

DC: A Stress Check-Up consists of obtaining a clear chronology of the patient’s symptoms followed by an evaluation for several different forms of psychosocial stress. An attempt is made to find connections between the physical illness and the sources of stress. Medical patients often are reluctant to undergo a “mental health assessment” or a “psychological exam” for a physical illness. Many will avoid scheduling an appointment with a mental health practitioner. The term “Stress Check-Up” carries far fewer negative connotations and may be more acceptable to patients.

PTPN: This group is forming a regional network of PPD trained practitioners. Why are regional networks so important in raising awareness of PPD? What role can they play in making it a first-line treatment to chronic pain?

DC: Few medical clinicians have had formal training in diagnosis or treatment of PPD. Consequently, when a patient’s diagnostic tests fail to uncover an explanation for symptoms, doctors are often uncertain about what to do next. This is the case for millions of patients in the US every year. Regional networks of trained PPD practitioners can reach out to primary care and other medical clinicians and raise awareness about PPD and the services they can provide to those patients. When patients report back to their doctor a positive or beneficial experience with a PPD practitioner, the medical clinician is likely to look for additional patients who might benefit.

PTPN: What challenges do you foresee this group and other regional networks having in trying to reach out to physicians?

DC: Medical clinicians, who care for the vast majority of PPD patients, are skeptical about any approach to patient care that is recommended by a non-physician. Most have limited or no familiarity with the concept that stress can cause virtually any severity of symptom in virtually any area of the body. For a therapist to change that mindset will be difficult and slow. What I hope for is that medical clinicians will begin by referring their most difficult and frustrating patients and observe good outcomes from PPD diagnosis and treatment. They will likely then refer their less severely afflicted patients until it gradually becomes a routine part of their practice. When I offered a class about PPD to a large group (80 or so) of primary care clinicians, only one patient came to the first class. Five years later, three dozen were attending every month. I am hoping for similar progress nationally over the next ten years.

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